infection control in intensive careanaesthesiaconference.kiev.ua/materials_2012/0037... · ignaz...

Infection control in intensive care

Sandra Fairley

Senior Nurse, Neurocritical Care [email protected]

Risks to the patient of health care acquired infection (HCAI)

Risk of HCAI

Increased length of stay

Increased morbidity

and mortality

AntibioticsClostridium Difficile

Antibiotic resistanceMRSA

Admit to Intensive Care Unit

HCAI +++Ventilator associated pneumonia

Vascular access device

HCAI +Site infection

Bacteraemia

Surgical procedure

HCAI ++Surgical wound infecton

Patient admitted to hospital

Risk of HCAI


Increased morbidity

and mortality







Bacteraemia

Surgical procedure




More patients treated more quickly

More gravely ill patients

High bed occupancy rates

In 2001

Estimated to be 9% of patients

admitted to NHS hospitals

in England

8.2% in 2006

6.4% in 2011


Risk of HCAI


Increased morbidity

and mortality







Bacteraemia

Surgical procedure




Risk of HCAI


Increased morbidity

and mortality







Bacteraemia

Surgical procedure



National Audit Office 2009

9,000 deaths with MRSA or C. Difficile

as underlying cause or contributory factor

Cost = £1.06 billion in UK

World Health Organisation

50% HCAI deaths attributable

to poor hand hygiene

Lessons from the past Link between hand hygiene and infection

Established in 1860

Lessons from the past

1847

Ignaz SemmelweissFather of hand hygiene

Link between hand washing & spread of disease

2005

World Health Organisation (WHO)First global hand hygiene

improvement strategy

2002Healthcare Infection Control Practices Advisory Committee

Alcohol handrub standard of care

Hand washing reserved for particular situations

2000

Didier PitierImproved hand hygiene compliance

with alcohol handrub

1860-1870

Pasteur and ListerScientific proof of link

1854

Florence NightingalePioneer of evidence based practice

with hand washing at its core

Embedded in religious and cultural habits

as measure of personal hygiene for centuries


1847



2005






2000



1860-1870


1854





Demonstrated that hand washing

prevented the spread of

childbirth fever

Instituted compulsory washing and

disinfecting of hands of all who

entered the obstetric ward

Cut mortality rate from 16% to 3%

Asepsis theory rejected by the

medical community during his

lifetime

Later proven by the work of

Pasteur and others

1847



2005






2000



1860-1870


1854






Identified connection between

hygiene and illness many years

before Pasteur’s germ theory

Most significant legacy as

hygienist and statistician

‘Every nurse ought to be careful to wash

her hands frequently during the day’

‘She must ever be on guard against

want of cleanliness …’


1847



2005






2000



1860-1870


1854






1847



2005






2000



1860-1870


1854





Hand hygiene compliance

improved with alcohol hand rub

This should be the standard of care

with hand washing reserved for

particular situations


1847



2005






2000



1860-1870


1854





Present day issues

2012

Present day issues

• Hand hygiene compliance – MRSA

– Clostridium Difficile

• Surgical site infection

• Intravenous line infection

• Ventilator-associated pneumonia

• Antibiotic resistance

Introduction of surveillance and targets

In UK reducing risk of HCAI

has become national priority

with the introduction of

surveillance and targets

MRSA bacteraemia

1.3% in 2006

0.1% in 2011

Clostridium Difficile

2% in 2006

0.4% in 2011

Hand hygiene

Most basic thing we can do –

but the easiest thing to get wrong!

Mandatory training

Monthly hand hygiene audits

Strict dress code

Bare below the elbow No jewellery

Plain wedding band allowed

No wrist watch

No nail varnish

MRSA

0

5

10

15

20

25

30

35

40

Apr to

Jun

2001

Jul to

Sep

200

1

Oct to

Dec

2001

Jan

to M

ar 2

002

Apr to

Jun

2002

Jul to

Sep

200

2

Oct to

Dec

2002

Jan

to M

ar 2

003

Apr to

Jun

2003

Jul to

Sep

200

3

Oct to

Dec

2003

Jan

to M

ar 2

004

Apr to

Jun

2004

Jul to

Sep

200

4

Oct to

Dec

2004

Jan

to M

ar 2

005

Apr to

Jun

2005

Jul to

Sep

200

5

Oct to

Dec

2005

Jan

to M

ar 2

006

Apr to

Jun

2006

Jul to

Sep

200

6

Oct to

Dec

2006

Jan

to M

ar 2

007

Apr to

Jun

2007

Jul to

Sep

200

7

Oct to

Dec

2007

Jan

to M

ar 2

008

Apr to

Jun

2008

Jul to

Sep

200

8

Oct to

Dec

2008

Jan

to M

ar 2

009

Apr to

Jun

2009

Jul to

Sep

200

9

Oct to

Dec

2009

co

un

t

Number of MRSA bacteraemias Quarterly counts not validated

Quarterly MRSA bacteraemia 2001 to 2009

UCLH target

2011 = 8

2012 = 5

MRSA

Elective admissions

All patients screened in pre-admission clinic or on admission to hospital - MRSA Rapid Test (MRAP)

If MRSA positive • Prescribed 5 day course of antiseptic skincare

– Chlorhexidine body wash and shampoo – Antibiotic nasal ointment - mupirocin – Chlorhexidine body powder

• Planned surgery takes place on day 5

• Chlorhexidine skin prep at operation site

• Teicoplanin 800mg IV + gentamicin 1.5mg/kg intra-op

MRSA Emergency admissions with unknown MRSA

status

• Take MRSA screen – MRSA Rapid Test (MRAP)

• Pre-op apply mupirocin to inside of nose

• Chlorhexidine skin prep at operation site

• Add Teicoplanin 400mg IV to conventional

surgical prophylaxis intra-op

• Continue MRSA suppression post-op until screen reported

Clostridium Difficile

• Isolate only in presence of diarrhoea and until no diarrhoea for at least 48 hours

• Use soap and water for hands – not alcohol gel

• Environmental cleaning with Chlorine Dioxide Antibiotics 1st line: • Metronidazole 400mg PO tds for 10 - 14 days

• If poor response after one week change to

Vancomycin 125mg PO qds for 10 - 14 days

1st line in severe cases: • Vancomycin 125mg PO qds for 10 - 14 days

UCLH Target

2012 = 44

Financial penalty of

£1 million for every case

over target

Careful antibiotic

prescribing Restrict use of

proton pump inhibitors

Surgical site infection

• Skin prep = Chlorhexidine with Tint – 2% chlorhexidine gluconate

in 70% isopropyl alcohol with tint

2-3 fold decrease in wound infection rates when compared to aqueous povidone iodine

• Intra-op – Surgical prophylaxis Single dose antibiotic adequate for most surgical procedures

• Post-op

– Wound dressing and suture removal protocols

Surgical site infections

account for up to 20% of all HCAI

5% of patients undergoing

surgical procedure develop

a wound infection

Hospital stay doubled

£65 million/year in UK

National Hospital rates

April – June 2012

Spinal surgery: 2%

(national average 2.1%)

Cranial surgery : 1.7%

(national average 1.9%)

Intravenous lines

• Improved design of

vascular access devices

– Closed system

– Needle free

• Protocols

– Insertion

– Duration

• Line dressings

– Chlorhexidine impregnated

Insertion details Who inserted the line and when

Visual Infusion Phlebitis (VIP) Score Early detection of IV site infection

Daily observation of insertion site

using VIP Score

VIP score

Valid and reliable measure for determining

when to remove a peripheral intravenous line

Cannula removal details

Ventilator-associated pneumonia

• Elevation of head of bed to 30o-45o

– Reduce risk of VAP

• Tubing management – Replace when visibly soiled and

according to manufacturer’s instructions – Prevent condensate entering airway

• Suctioning of respiratory secretions – Wear examination gloves and

decontaminate hands before and after suction procedure

• Oral hygiene – Chlorhexidine mouth wash QDS

• Sedation holding – Reduce duration of mechanical

ventilation and risk of VAP

• Gastric ulcer and DVT prophylaxis – Prevent complications of critical care

Respiratory infections

4th largest contributor

to HCAI in UK

19% ventilation-related

Internationally accepted

evidence-based guidelines

to prevent VAP

Prudent antibiotic prescribing

Guidelines on antibiotic

prescribing help eliminate

their misuse

Guidelines on best practice in

taking blood cultures help reduce

risk of contaminated samples

Waiting for objective data to diagnose

infection before treatment with antimicrobial

drugs for suspected ITU acquired

infections does not worsen mortality and

might be associated with better outcomes

and use of antimicrobial drugs

The Lancet Infectious Diseases October 2012

Prudent antibiotic prescribing

ICU Antimicrobial Guidelines

Clinical Guideline - DRAFT

Local use

Author(s)

Dr R Hurley (on behalf of Critical Care Delivery Group) Prof P Wilson, Consultant Microbiologist Dr B Macrae, Consultant Microbiologist Dr N Shetty, Consultant Microbiologist Dr C Curtis, Consultant Microbiologist Dr S Morris-Jones, Consultant Microbiologist Ms P Panesar, Lead Pharmacist, Microbiology

Owner/Sponsor Critical Care Delivery Group

Review By Date 1st January 2013 (or earlier if new evidence becomes available)

Responsible Director Dr R Hurley Chair of Critical Care Delivery Group

Monitoring Committee Critical Care Delivery Group Antimicrobial Usage Committee

Target Audience

All medical, nursing and pharmacy staff

Related Trust Documents/Policies

Gentamicin dosing guideline – Adults

Neutropenic sepsis guideline

Clostridium difficile treatment guideline

Meningitis treatment

Endocarditis treatment

Number of Pages and Appendices

7 pages

Equalities Impact Assessment

Low

Updated antimicrobial guidelines

for ITU patients

Updated antimicrobial guidelines

for ward patients

ALWAYS take cultures

BEFORE starting antibiotic therapy

All prescriptions must have

a STOP or REVIEW date

Not only the behaviour of health care

professionals that determines the risk

of HCAI but also the behaviour of

patients and visitors to our hospitals

Informing patients and their relatives

HCAI is costly for the patient and

for health care organisations

Reducing the probability of HCAI

will continue to be a priority

worldwide

Thoughts for the future

Most HCAIs occur in the

intensive care unit (23.4%)

Patients are sicker

Have more invasive devices

Need more ‘hands on’ care

The basics will continue to be key to

infection control in the ITU

Hand hygiene

General cleaning of the environment

Isolating infected patients

We know they work!

Thank you